Citation Nr: 0007110 Decision Date: 03/16/00 Archive Date: 03/23/00 DOCKET NO. 95-21 212 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office and Insurance Center in St. Paul, Minnesota THE ISSUE Entitlement to service connection for impotence on a secondary basis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. S. Tierney, Counsel INTRODUCTION The veteran served on active duty from December 1943 to June 23, 1946, and from June 30, 1946, to September 1952. This matter came to the Board of Veterans' Appeals (Board) on appeal of a decision of the Department of Veterans Affairs (VA) Regional Office and Insurance Center (RO) in St. Paul, Minnesota. The Board notes that the RO has framed the issue for appellate consideration as whether new and material evidence has been received to reopen a claim for service connection for impotence on a secondary basis. The RO has framed the issue in this manner because it has construed a February 1966 Board decision as a final prior denial with respect to the veteran's claim for service connection for impotence on a secondary basis. The record reflects that the veteran has been granted service connection for neuropathy of the left pudendal nerve resulting from surgery for his service-connected left hip disability. In its February 1966 decision, the Board denied special monthly compensation for loss of use of a creative organ based on its determination that the presence of impotence had not been demonstrated. In this decision, the Board did not deny service connection for any disability. Therefore, in the Board's opinion, the veteran's claim for service connection for impotence should be addressed on a de novo basis. In any event, the record reflects that medical evidence indicating that the veteran is impotent and that the impotency is at least partially due to service-connected disability has been added to the record since the February 1966 Board decision. Therefore, reopening of the claim would be in order even if the February 1966 Board decision were construed as a final denial of the claim for service connection for impotence. Finally, in view of the Board's decision in this appeal, the issue of entitlement to special monthly compensation for loss of use of a creative organ is referred to the RO for appropriate action. FINDINGS OF FACT 1. All available evidence necessary for an equitable disposition of the appeal has been obtained. 2. Service-connected neuropathy of the left pudendal nerve materially contributed to the veteran's impotency. CONCLUSION OF LAW The veteran's impotence is proximately due to or the result of service-connected disability. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has found the veteran's claim to be well grounded and is satisfied that all available evidence necessary for an equitable disposition of this claim has been obtained. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In addition, when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected condition, the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The veteran's service-connected disabilities include neuropathy of the left pudendal nerve resulting from surgery for service-connected disability. A VA hospital report dated from October to November 1963 notes that after March 1963 surgery to remove a fragment adjacent to the left ischium, the veteran had had pain in the left lumbar area, left buttock and left hip with rare radiating pain into the inner aspect of his left thigh. In addition, for the past several months, he had noted severe left scrotal pain two to three times a day. It was noted that the veteran had not had this pain pre-operatively. The veteran also reported that the left side of his scrotum felt numb. His penis felt all right and these pains were not aggravated particularly by coughing, straining, etc. It was further noted that, though diminished in frequency recently, sexual function appeared all right to the veteran. Examination showed a normal penis and testes. Examination of the rectum and prostate revealed a four by four centimeter smooth immobile mass in the left ischial rectal fossa region impinging on the rectum. Neurological examination was completely within normal limits except for an area of hypesthesia and hypalgesia on the left side conforming to the cutaneous distribution of the left pudendal nerve. The admitting impression was a mass in the left ischial rectal fossa region involving the perineal, scrotal and dorsal penis branches of the pudendal nerve. During the hospitalization, the veteran underwent surgery and a benign cystic structure was removed. It was noted that post- operatively he did well. The final diagnosis was benign presacral cyst, involving left pudendal nerve. VA outpatient treatment records contain an entry dated in December 1963 which shows that the veteran complained of occasional mild episodes of left testicular pain but not as much as before. Another entry dated in March 1964 notes that the veteran had no testicular pain. A VA examination report dated in June 1964 notes that several years previously, the veteran began to notice neurological and sensory pain sensations that radiated into the left peroneal area and extended up as far as the scrotum. It was further noted that this was progressive. In addition, it was noted that following excision of the presacral cyst, he had marked improvement of the sensory disturbances into the peroneal area, although he currently still had some residual numbness into the scrotum. The examiner, however, did not examine or note objective findings of numbness of the scrotum or residuals involving impotence. A VA hospital report dated in February 1965 shows that the veteran was treated for chronic low back strain and impotence. It was noted that the impotence was of approximately two years' duration and was associated with pain in the left pudendal area. The physician noted that the veteran had had surgery for removal of a presacral cyst which involved the left pudendal nerve. It was further noted that the nerve was sectioned in order to remove the cyst and the veteran's impotence was probably increased following section of that nerve. The pertinent diagnosis was impotence, secondary to transection of left pudendal nerve. A report of contact dated in April 1965 with the same physician that signed the February 1965 VA hospital report shows that the doctor was of the opinion that the veteran probably could impregnate his wife, he could have an erection but was not capable of maintaining it during intercourse, and the impotence was of such a degree as to cause a strained marital relationship. A VA neurological consultation report dated in April 1966 shows that the veteran was found to have sensory changes in the distribution of the left pudendal nerve due to sectioning of the nerve and that the sensory changes were contributing to his impotence. At a VA examination in July 1970, the veteran reported that he had numbness in the left testicle. The examiner did not note any examination findings in regard to the veteran's complaint of numbness in the left testicle. The diagnoses included removal of presacral tumor with severance of the left pudendal nerve. A VA examination in July 1973 revealed that because of the history of resection of the left pudendal nerve, testing about the penis and the perineum was carried out and showed that the cremasterics were equal bilaterally whereas previously the left cremasteric was decreased. Pinprick testing of the phallic area revealed that the sensation on the left side was slightly decreased compared to the right. The diagnoses included neuropathy, left pudendal nerve, secondary to operative resection; partly recovered from. A letter dated in January 1995 from a VA staff physician of the urology section notes that the veteran was evaluated in December 1994 for evaluation of erectile dysfunction, which the veteran stated he had had for at least 20 years. It was further noted that after the presacral cyst was removed in October 1963, the veteran felt that there was some loss of sensation in his genitalia area although the erectile function was intact at that time. Since the operation, the veteran had experienced a gradual decline in his ability to achieve erection and also a gradual decrease of sensation in his genitalia area. The physician also noted that for the past 20 years, the veteran had not been able to achieve any meaningful erection. The physician provided his opinion that the severance of a major pudendal nerve branch may have contributed to the veteran's loss of erectile function and, although the cause of the veteran's impotence was multifactorial, his previous surgery was at least partially responsible for his disability. A VA genitourinary consultation report dated in March 1995 notes that the veteran's impotence may be multifactorial and that it is difficult to determine with certainty if the veteran's operations in the past may have caused his impotence. The veteran testified at a personal hearing in August 1995 before a hearing officer at the RO. He stated that he had no problems having erections prior to the surgery in 1963. He indicated that his ability to have erections was diminished after the first surgery in 1963 and it became a total problem after the subsequent surgery to remove a tumor which involved the nerves. The veteran testified that he could not ejaculate to any great satisfaction and that he has lost total erectile power. At a VA examination in May 1997, the veteran reported beginning difficulty in obtaining an erection soon after the injury to his back and left hip in 1945. This problem increased by 1963 and he developed complete impotence by 1968. Examination of the groins and genitals showed no abnormality. The diagnoses included impotence. After a review of all the evidence of record, the Board finds that the preponderance of the evidence supports the claim for service connection for impotence on a secondary basis. In this regard, the Board notes that the medical evidence establishes the presence of impotency and that the service- connected neuropathy of the left pudendal nerve, at a minimum, contributed to the impotency. There is no medical evidence indicating that the service-connected neuropathy did not contribute to the veteran's impotency. Therefore, service connection is warranted for this disability. ORDER Service connection for impotence on a secondary basis is granted. SHANE A. DURKIN Member, Board of Veterans' Appeals